Across
- 5. A provider not contracted with a plan’s insurance network. Claims from out-of-network providers are generally subject to higher out-of-pocket costs to the member.
- 8. A health insurance plan that offers flexibility to see any doctor, with lower costs for using in-network providers and no referral needed to see specialists.
- 9. A U.S. law that protects the privacy and security of individuals' medical information and ensures health insurance coverage continuity when changing or losing jobs.
- 10. A U.S. law that protects patients from unexpected medical bills for emergency services and out-of-network care at in-network facilities.
- 12. A significant life change that allows individuals to enroll in or adjust their health insurance coverage outside the typical open enrollment period.
- 14. A type of cost-sharing where a dollar amount is set and must be met before insurance starts to pay covered expenses.
- 19. A legal document required under the Employee Retirement Income Security Act (ERISA) that provides participants in covered retirement or health benefit plans with a clear, understandable summary of their plan's benefits and rights.
- 22. A doctor or hospital that has a contractual agreement with an insurance network to provide services at a lower cost.
- 25. A type of health insurance plan that allows patients to see any doctor or specialist regardless of network status and reimburses them for a portion of the costs, usually after they pay out-of-pocket and submit claims.
- 26. A specified time frame between when a member becomes eligible and when they can begin using certain benefits or receive coverage. It essentially means there's a delay before full coverage becomes effective.
- 28. A health insurance plan that requires members to choose a primary care physician (PCP) and get referrals to see specialists, typically only covering in-network care.
- 29. Timely enrollment refers to enrolling in a program or benefits within a specified timeframe, usually after becoming eligible.
- 30. A health insurance plan that categorizes providers, services, or treatments into different levels (or "tiers"), with lower costs for services from higher-tier (preferred) providers and higher costs for lower-tier providers. Higher-tier provider benefits tend to be better than in-network provider benefits.
Down
- 1. The amount a member pays regularly (monthly or yearly) and is collected by their employer to have health insurance. Employers may use these to cover the cost of the claims themselves or to cover PEPM’s.
- 2. A health insurance plan with lower premiums and higher deductibles, often paired with a Health Savings Account (HSA) to help pay for medical expenses.
- 3. A federal law that allows employees and their families to continue their employer-sponsored health insurance for a limited time after losing coverage due to job loss or other qualifying events, usually at their own expense.
- 4. Refers to the member’s portion of costs for healthcare services covered by their health insurance plan.
- 6. A U.S. law enacted in 2010 that expanded health insurance coverage, prohibited coverage denial for pre-existing conditions, and introduced subsidies and marketplaces to make insurance more affordable.
- 7. The maximum amount a member can pay in a year for covered services. After the out-of-pocket is met, insurance pays 100% of covered expenses.
- 11. A health insurance plan where the employer pays a fixed premium to an insurance carrier, which assumes all financial responsibility for employee healthcare claims.
- 13. A federal law that sets standards for private employer-sponsored benefit plans, including health and retirement plans, to protect employees' rights and ensure fair management of plan funds.
- 15. A health insurance plan that only covers care provided by in-network doctors and hospitals, except in emergencies, without requiring referrals for specialists.
- 16. A type of health insurance option where employers pay for their employees' medical claims directly while a third-party administrator (TPA) typically administers the plan by handling the administrative tasks associated with the claims.
- 17. A period during which one may freely enroll in or change one's selection of a health insurance plan or other benefit program.
- 18. A PEPM refers to a payment structure where employers contribute a fixed amount for each employee's insurance coverage every month to the TPA for plan administration.
- 20. Refers to the criteria an individual must meet to qualify for enrollment in a health insurance plan, such as age, income, employment status, residency, or immigration status.
- 21. A type of cost-sharing where the member pays a fixed amount for a healthcare service (e.g., $20 for a doctor visit).
- 23. A federal law that requires group health plans and insurers to cover breast reconstruction and related services after a mastectomy.
- 24. A hybrid of HMO and PPO. Members need a referral for specialists but can go out of network for care at a higher cost.
- 27. A type of cost-sharing where the member pays a percentage of costs for covered expenses after the deductible has been met (e.g., member pays 20%, insurance pays 80%).